Improving childhood pneumonia detection in vulnerable settings

Piloting the Children’s Automated Respiration Monitor (ChARM) tool in humanitarian settings in Chad and Uganda

About

Pneumonia is the world’s leading infectious disease killer of children under five, accounting for more than 800,000 – or around 15% of child deaths annually. Nearly half of all these deaths occur in sub-Saharan Africa. If children are diagnosed early and correctly, pneumonia can be easily treated with affordable oral antibiotics. Severe cases can be referred to facilities that are better equipped to deliver advanced care. However, inaccurate diagnosis, inadequate supplies of medicines and weak referral systems remain a challenge in fighting the disease in low- and middle-income countries and in humanitarian contexts.

WHO guidelines

According to the World Health Organization (WHO) international guidelines for the management of pneumonia, assessment of a child’s respiratory rate is a critical component for diagnosing children with pneumonia in low-resource settings. However, counting respiratory rates is challenging, particularly in children as they may breathe irregularly, and it can be difficult to keep them calm for an entire minute. Miscounting by community health workers and even health providers is common, which can lead to inaccurate diagnosis and treatment.

The Philips Children’s Automated Respiration Monitor (ChARM) was developed in response to this challenge. The ChARM device automatically measures the respiratory rate of a child and classifies the breathing rate according to the WHO guidelines for childhood pneumonia.

Complementing earlier studies of ChARM, this project specifically evaluated the effectiveness of ChARM by community health workers in low literacy refugee settings in Chad and Uganda.

Partners

How

The International Rescue Committee (IRC) led a mixed-methods research design to evaluate the effectiveness of the ChARM tool among Community Health Workers (CHWs) implementing Integrated Community Case Management (iCCM) in areas hosting refugees in Chad and Uganda.

The research aimed to answer three main questions:

1. To what extent are CHWs able to correctly use the ChARM tool?

2. What is the effect of the use of the ChARM tool by CHWs in the facilitation of the identification, classification, and treatment of pneumonia in children under five?

3. What is the impact of the ChARM tool on the quality of care provided for children under five with suspected pneumonia?

A total of 132 CHWs participated in the Quality-of-Care assessment (roughly equally divided between Chad and Uganda, and between intervention and control groups).

Results

Overall, the findings showed that the ChARM device improved CHW’s ability to accurately diagnose pneumonia versus cough/cold.

In Chad, there were 18% fewer misdiagnosed cases of cough/cold and 26% fewer misdiagnosed cases of pneumonia in the intervention group compared to the control group. In Uganda, there were more than 50% fewer misdiagnosed cases of cough/cold in the intervention group, though the intervention group did not perform better on pneumonia diagnosis.
There were notable differences in the assessment and classification of respiratory rates between the intervention and control groups in both countries. In Uganda, correct measurement of respiratory rate was 17% higher in the intervention group (71% in the control group compared to 88% in the intervention group). In Chad, the intervention group had 100% correct measurement of respiratory rate vs. 63% in the control group. Correct classification of pneumonia based on the respiratory rate was also better in the intervention group in both countries.
The ChARM device was well accepted by the communities as it provides immediate results and gives caregivers a stronger sense of confidence in the results/diagnostics.
Importantly, the ChARM tool was observed to help lessen the pressure on CHWs to provide antibiotics when a child was shown to not have pneumonia, as results coming from the device helped the caregivers and community members accept this fact.

Learnings and next steps

The red/green reading on the device helped CHWs to explain the decision and overcome resistance to not giving antibiotics to children diagnosed with a simple cold.
When a CHW assesses a sick child, the first step should be judgment of danger signs and symptoms (for pneumonia, but also for diarrhea and malaria). While the use of the ChARM device proved effective in subsequent pneumonia classification, one intervention group performed worse on such initial danger sign evaluation. The exact reason could not be determined (a suspicion could be overreliance on technology), but it does highlight the importance of continued on-the-job training and supportive supervision to reinforce the capacity of CHWs.
Accurate diagnosis of pneumonia is only one component of tackling childhood pneumonia. Access to essential medicines, including antibiotics, is necessary for comprehensive care. Although this was not the main aim of the study, it was observed that CHWs were able to appropriately treat children with the correct dosage of medicines based on the diagnosis (both intervention and control group).